Telemedicine: What, How, And Why!

Lucas Lumbley, CAPMTelemedicine Manager

May 17, 2016

University Health System

• Nationally recognized academic medical center and network of outpatient health centers

• Lead Level I Trauma Center for 22 South Texas counties

• Community First Health Plans

• Community Medicine Associates

• Teaching partner with University of Texas Health Science Center

A Higher Level Of Care

University Hospital, in partnership with UT Medicine • Level I Trauma Center

• Level II Pediatric Trauma Center

• Pediatric Burn Program

• University Transplant Center

• Maternal/Fetal Medicine

• Level III Neonatal ICU

• Heart Vascular Lung Institute

• Certified Stroke Center

• Certified Palliative Care Program

• Level 4 Epilepsy Center

Magnet: The “Gold Standard” in patient care

5% of U.S. hospitals

U.S. News & World Report:

#1 in San Antonio

#6 in Texas

Top 50 in the U.S. for Nephrology

CNOR Strong

Certified

National Quality Measures for Breast Centers™

FOCUSED ON EXCELLENCE. ACHIEVING RESULTS

U.S. HHSC2009 - 2014

Executive Director’s Award2013 Excellence

through Diversity Award

Specialized care:

Good health, safety & supporting our community:

Technology, employee learning & efficiency:

What is telemedicine?

• Telemedicine vs. Telehealth

Telemedicine

Live InteractiveStore and Forward

Remote Patient Monitoring

What is the Need for Telemedicine?

• Shortage of providers and specialists across the region

• Increased efficiency– Hub and spoke model

• Benefits to patient– Increased access

– Increased convenience

– Decreased associated costs

• Patient Demand

For what can telemedicine be used?

Telemedicine Use Cases

• Emergency Medicine

– Tele-stroke

• Chronic Disease Management

– Neurology, Nephrology, Hepatology, Infectious Disease, Urology

• Behavioral Health

• Post Discharge Follow Up

• Patient Education

• Provider Education

Telemedicine at UHSSpecialty Benefit

Infectious Disease - Jail Increased access/quality of care, increased provider efficiency

Nephrology - Jail Increased access/quality of care, increased provider efficiency

Neurosurgery Increased provider efficiency

Rehab Increased provider efficiency, increased training for clinic staff

Endocrinology Increased access to care

Ophthalmology Increased quality, increased care delivery model, increased access to care, significantly increased show ratio

Diabetes Education Increased access to care, improved clinical outcomes

Urology Increased access to care

Nephrology Increased access to care

Hepatology Increased access to care

Neurology Increased access to care

Implementing a Successful Telemedicine Program

• Obtain stakeholder buy-in– Registration, clinic staff, providers, IT, billing, etc.

• Select the appropriate project– Does the specialty have a stance on telemedicine?

– What kind of patients can we see?

– How does reimbursement work?

• Define success metrics– Clinical, operational, financial

• Build an appropriate infrastructure

Building an Appropriate Infrastructure

• Equipment- HIPAA Compliance

- Scale to what you need• Peripherals?

- Ease of use is important

- Interoperability is key• Do you need images or videos

saved?

• Utilizing your medical record- Do you have sufficient documentation?- Ensure continuity of care

Contracting and Telemedicine

• Pay per click model– Fee for service

– Cost per patient or cost per visit

• Pay for time model– Pay for specialist time, usually in block, and you are responsible

for booking the patients

• Pay for volume model– Similar to capitated model

Lessons Learned

• Make sure you have appropriate pre-visit workup

• If technology or workflow isn’t easy, adoption will be poor

• Educating patient on telemedicine should be a high priority– Increase show rate

– Increase patient satisfaction

• Telemedicine can be used for many but not all scenarios

Reimbursement

• Texas Medicaid Pink Book1

– Two distinct definitions of telemedicine and telehealth

– Patients must receive in-person evaluation for same diagnosis or condition being rendered via telemedicine.

• Excludes mental health if purpose of telemedicine is to screen and refer for additional services

• To continue receiving services, patient must have an in-person evaluation at least once within 12 months before receiving telemedicine.

– Requires written informed consent

TelemedicineDistant Site & Patient Site

• Distant Site – location of provider rendering services- Must be one of the following:

• Physician• CNS• NP• PA• CNM

• Patient Site – where the client is physically located while the service is rendered

- Must be one of the following:• Established medical site• State mental health facility• State supported living center• Schools2

• Tele-presenter must present the patient

TelehealthDistant Site & Patient Site• Distant Site – location of provider rendering services

- Must be one of the following:• Licensed professional counselor• LMFT• LCSW• Psychologist• Licensed psychological associate• Provisionally licensed psychologist• Licensed dietician

• Patient Site – where the client is physically located while the service is rendered

- Must be one of the following:• Established health site• State mental health facility• State supported living center• Schools2

• Tele-presenter must present the patient and be readily available- Exclusion for services relating only to mental health

Billing for Telemedicine/Telehealth

• Normal procedural code but added modifier for telemedicine/telehealth– 99213 in person would be 99213-GT in telemedicine

• Patient site bills for the facility fee– For telemedicine, Q3014

• Q3014 is not a benefit for telehealth services.

Billing for Tele-monitoring

• Set up and installation code - 99090• Online evaluation and management for home tele-monitoring services

- 99444 – office or outpatient hospital setting• Services provided by NP, CNS, PA, MD• Can be billed once per seven days

- 99090 GQ – home health agency or outpatient hospital• Can be submitted daily

Private Payers

• 1997 - TX enacted a private insurance parity law3

Live – Interactive Specialty TelemedicineInitial Cost

Session 1 Session 2 Session 3 Session 4 Session 319

Expenses

Hardware $2,000 - - - - -

Training - - - - - -

Overhead/Staffing - $100.00 $100.00 $100.00 $100.00 $100.00

Physician Time - $450.27 $450.27 $450.27 $450.27 $450.27

Gross Cost $2,000 $550.27 $550.27 $550.27 $550.27 $550.27

Benefits

Visit Income - $556.54 $556.54 $556.54 $556.54 $556.54

Net benefit - $6.27 $6.27 $6.27 $6.27 $6.27

Cumulative Total ($2000) ($1993.73) ($1987.46) ($1981.19) ($1974.92) $0

*Overhead/Staffing calculated using 25$ per hour for MA salary/benefits, overhead, and small portion of registration salary.*Physician Time based off of Median Salary for endocrinologist*Visit income based off of 4 hour time slots (2 new-patient and 5 follow-ups)

(99214*2 and 99213*5)

• Increased access to care for patient

– Increased patient satisfaction

• Increased show ratio

• Increased provider satisfaction

Non-Traditional Benefits

Store and Forward-OphthalmologyInitial Cost

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6

Expenses

Hardware $73,800 - - - - - -

Training $2,500 - - - - - -

Overhead/Staffing - $16,000 $16,000 $16,000 $16,000 $16,000 $16,000

Interpretation - $24,000 $24,000 $24,000 $24,000 $24,000 $24,000

Gross Cost $76,300 $40,000 $40,000 $40,000 $40,000 $40,000 $40,000

Benefits

Eye Photo Income - $60,828 $60,828 $60,828 $60,828 $60,828 $60,828

Net benefit - $20,828 $20,828 $20,828 $20,828 $20,828 $20,828

Cumulative Total ($76,300) ($55,472) ($34,644) ($13,816) $7,012 $27,840 $48,668

*Overhead/Staffing calculated using 25$ per hour for MA salary/benefits, overhead, and small portion of registration salary.*Eye Photo Income - Calculated using minimum of 1200 visits for each facility multiplied by the facility portion of 92250 code

Non-Traditional Benefits

• Increase in appropriateness of visits- Pre-screening allows more abnormal eyes to get seen in clinics

• Increase in percent of patients with annual eye screening• Increased show ratio

Avg. telemedicine eye screening– 12 min. Avg. in person screening – 30 min.

The Future of Telemedicine

Questions?

References1. Texas Medicaid Provider Procedures Manual April 2016

http://www.tmhp.com/TMPPM/TMPPM_Living_Manual_Current/Vol2_Telecommunication_Services_Handbook.pdf

2. Texas State Legislature 2015 Session HB 1878; http://www.capitol.state.tx.us/tlodocs/84R/billtext/pdf/HB01878F.pdf#navpanes=0

3. TX Insurance Code, Title 8, Sec. 1455.004